"Adjuvant" similar to "Early Salvage" Radiation Outcome in Meta-analysis

[Tall_Allen]

Some men can wait in order to prevent overtreatment and unnecessary treatment toxicity.

pcnrv.blogspot.com/2019/09/...

[GreenStreet]

Thanks for posting. Very interesting. I faced the difficult decision in 2016/17 and went with ESRT and 6 months hormone therapy rather than ART. Unfortunately I have biochemical reoccurrence with my recent September PSA at 0.04. I will never know whether Adjunct would have been better than ESRT. My PSA was 0.06 when I started HT before ESRT but the radiation was 2 years 4 months after the RP. Back then decipher was little know about in UK.

[Tall_Allen in reply to GreenStreet]

In those studies they would not have called you biochemically recurrent after eSRT with a PSA of just 0.04. They used PSA ≥ 0.4 ng/mL and rising after completion of radiotherapy.

BTW - Can't you still have salvage radiation to your pelvic LNs?

[GreenStreet in reply to Tall_Allen]

I am not sure. I did push for the pelvic LN’s to be done but they were adamant that on a risk basis they should not be done. I think the plan now is to monitor extent of PSA progression and do a Gallium scan either at 0.2 or more likely at 0.5 and take it from there. I think if anything was found in pelvic LNs they would consider doing. But it does not sound a curative solution although they have not explicitly said that. I contrast the attitude post RP where they were very anxious to radiate after third PSA rise (even when PSA went down and only got back to the place where it started) with the wait and see approach that they are taking now. Do you think I should ask about immediate action on pelvic LNs? They are really not sure where “it” is.

[Tall_Allen in reply to GreenStreet]

Maybe share this link with them and ask for their comments:

pcnrv.blogspot.com/2019/08/...

If validated, this explains why salvage prostate bed radiation is often unsuccessful.

There may be anatomic reasons why pelvic radiation would be risky for you in particular. Guys without much protective visceral fat may get excessive organ exposure.

[GreenStreet in reply to Tall_Allen]

Thanks very much for this. That is really interesting. I wish I had the info when I was unsuccessfully pushing for eSRT to include LN. I guess they would say that the study suggested that low PSA (and a positive margin) made it unlikely to be in LN. Both my surgeon and oncologist thought not in LN. Are you suggesting that I should consider pushing for radiation now “blind” rather than waiting for PSA to go to 0.2 or 0.5 and do the PSMA Pet scan which they plan to do and then take targeted action. Waiting means a greater chance of spreading. I did have a bone scan pre my RP in 2015 when my PSA was 14.6 and nothing was detected. Ironically I only got this because I was considering Proton treatment at Munich and they insisted. As I understand it the best outcome I could have is that it is in the PLN rather than prostate bed. I only got 66 gray into Prostate bed but I pushed for HT for synergistic impact. I also exercised vigorously just before each radiation session because I read somewhere that this could enhance the impact of radiotherapy so perhaps unlikely it is still in prostate bed. Appreciate your further views.

[Tall_Allen in reply to GreenStreet]

Is there any chance of your going for a Combidex MRI at Radboud University in Nijmegen, The Netherlands? Jelle Berenz has found that it can find LN mets half the size of other PET scans. To my knowledge, it is the only place in the world you could get it.

[GreenStreet in reply to Tall_Allen]

Thanks v much I will look into this, I could get over there

[Murph256]

I had early SRT to my entire pelvic region and prostate bed 8 months after my RP, when my PSA hit .62, and then fell back to .55. I am happy to hear that there is little difference in outcomes between eSRT and ART.

There seems to be an ongoing controversy as to whether ADT should have been included with my eSRT. At a PSA of .55 or .62, my MO and RO decided to error on the side of caution and include 24 weeks of ADT.

As miserable as the ADT was to endure, I would take it again, even if it improves my chances of 5 year event free survival by only a few percentage point or more, depending on the study.

[Hidden in reply to Murph256]

Sorry to note that your sRT could, by no means, defined as early.

Early used to be considered when RT started prior to PSA = 0.5

In the specific studies "early" was specified as PSA <0.2

The current trend is to lower this trigger value to <0.1

[Tall_Allen in reply to Murph256]

I wouldn't call that "early." To be included in their studies, PSA had to fall to undetectable and then rise to 0.1 or 0.2. If PSA never becomes undetectable after prostatectomy, it is called "persistent," and is treated immediately with ADT and pelvic lymph nodes.

[Justt in reply to Tall_Allen]

What's exactly immediately? My 1st psa post RP at 6 weeks read 0.17, but 5 days later decreased a bit to 0.13. I'm about to get a new one next week (week#8).

Though I dont face incontinence or ED problems, my report shows 2 positive margins of 2.5 and 3.5mm..It seems then the procedure failed on its main purpose..The surgeon said my procedure was "difficult" for a whole anteriorly located tumor of 2.5 cm.. There was EPE reported too, though I read this definition can be very controversial to establish in the anterior zone..

After all this mess, I rushed to a very good radiation oncologist and his advice was to start RT (70gy) along with 6 months ADT/Zoladex by the end of november, around 4 months ahead of surgery..

The surgeon, instead, was a bit ironic stating there's no such point to hurry or even evidence to support a 2nd round of aggressive treatment..

Frankly, I entrust the RO much, much better. What do you think?

[Tall_Allen in reply to Justt]

"immediately" in that study meant within 6 months of surgery. "Adjuvant" usually means before the first (3 month) PSA test. There was a Czech study of men with positive margins that looked for the earliest time when the predictive accuracy was high enough on which to base a decision. It seems to be at least 2 months. At 2 months, any PSA above 0.04 reliably predicts biochemical failure for men with positive margins. So you'll be in a better position to decide next week when you have your next PSA test.

pcnrv.blogspot.com/2017/07/...

The two most important risk factors for men with positive margins is the length of the positive margin (which you gave) and the Gleason score at the margin (which may be on your pathology report). Gleason pattern 3 at the margin may only require surveillance; Gleason pattern 5 at the margin requires salvage radiation. If you are on the fence, a Decipher test may aid your decision.

Use of adjuvant ADT with salvage radiation may not be required if your 3-month PSA continues to be below 0.6. Although that is still very much a matter of judgment - if you had a high Gleason score or a rapid PSADT, for example. The same considerations hold true for whether your pelvic lymph nodes require salvage radiation.

[Justt in reply to Tall_Allen]

So grateful for your comments..I'm gleason 7, judged 60%4 and 40%3..One margin was 4 and the other 3..No SVI, and no limphonodes but confirmed PNI..

Hopefully, once these cells are still limited to the prostatic bed there might have a chance I can get rid of them with the programmed radiotherapy as the RO considers myself high-risk, even though the urologist/surgeon does not yet..

Tks 🙏